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The Joint Commission tackles its own processes with lean and Six Sigma

Published: 25 Oct 2010 23:01:19 PST

by Nicole Adrian, contributing editor

In 50 Words or Less:

  • The Joint Commission recently looked inward to improve processes and customer service.
  • The improvement process started with five internal projects and a Green and Black Belt training program.
  • The organization understands the importance of applying tools and ideas in-house that it promotes externally.

Many companies and organizations talk big about knowing the best way other businesses and groups can work to drive continuous and process improvement. Often, these businesses don’t take their own advice. Once in a while, however, a group comes along that can walk the talk.

The Joint Commission has proven it can do just that. Recently, the not-for-profit organization, based in Oakbrook Terrace, IL, developed its own Green Belt (GB) and Black Belt (BB) training program and kicked off internal improvement projects. Officers and staff believe this internal work will drive customer satisfaction, financial discipline and quality of the processes.

The organization, led by president Mark R. Chassin, M.D., accredits and certifies more than 16,000 healthcare organizations and programs in the United States. The organization strives to continuously improve the safety and quality of care provided to the public through the provision of healthcare accreditation and related services that support performance improvement in healthcare organizations. 

The Joint Commission staff wanted to use lean and Six Sigma to be more efficient, lower costs and operate better, said Rick Morrow, director of business excellence. "What we’ve done in the past hasn’t gotten us to where we want to be," he said.

The Joint Commission also understands the importance of applying the tools and ideas in-house that the organization promotes externally. "I think that there have been times in the past where we have tried to introduce something to the healthcare field, but we weren’t really applying it internally," said Paul Schyve, M.D., senior vice president and ASQ member. "I think what Mark has done is determine why we need to walk the talk."  

There are three central reasons why the tools and methods needed to be introduced, Schyve said:

  1. "We need to do it for ourselves—this is the way we make ourselves better and to better serve customers."
  2. "We need to show we’re walking the talk so other people don’t say, ‘That’s fine for you to tell us we should be doing this, but how come you don’t apply it to yourself?’"
  3. "If we’re going to help others, we need a really good understanding of the tools and concepts—it makes us better mentors to the field."

Chassin took on the roles of a teacher and mentor to the staff, Schyve said. "Soon after he got here, he started having very interactive but didactic sessions with those in the organization to talk about how this thinking was different."

Training belts   

To start the shift to using lean and Six Sigma, the organization developed its own training program to meet a need for a continuous process to train, empower and engage all employees quickly, Morrow said. "We believe that a leader’s role includes teaching and coaching in quality improvement. The training program includes high-reliability methods and a unique roadmap for any project team to be successful in figuring out complex problems."

It’s important for the Joint Commission to have GBs and BBs as part of its staff and business units to improve internal processes, Morrow said. This better satisfies customers’ expectations and, in turn, helps those customers improve patient safety and quality, he added. 

"Let’s understand how we do this ourselves so that we better understand how it will work in healthcare organizations," Schyve added. "I think that was one of the reasons for saying ‘Let’s develop our own training program.’"

In the first wave of certification, 20 employees took the GB certification course. From those 20, two were recently promoted to BB, said Ann-Marie Benedicto, executive vice president and chief of staff. "We felt it was very important to grow our own," she said.

Getting started

In addition to the belt training program, staff started five internal projects to improve the organization and, in turn, benefit customers.

"We tried hard to say, ‘What are our internal processes that are most greatly going to benefit our clients and customers?’" Morrow said. "We felt we had a good product that would really help patient safety and quality."

Before the five projects were selected from a list of 148 potential choices, they had to be analyzed and three criteria had to be considered, Benedicto said. The criteria were:

  1. Customer satisfaction.
  2. Financial discipline.
  3. Quality of the processes.

Additionally, two other important factors had to be considered, Schyve said. "The projects had to be those that the GBs-in-training would be able to handle," he said. "Also, the projects needed to be things that, when they succeeded, everyone in the organization would say, ‘That was important; this really helps us.’ It had to do with the training and the message to the rest of the organization about why this was important."

The officers and teams worked to tie the organization’s projects to key dissatisfiers, said Charles Mowll, executive vice president of business development, government and external relations.  They also worked to get back to the main criteria that qualify the project to drive internal performance excellence with real results to improve the value to customers, he added. 

The first five internal projects the Joint Commission worked on were:

  1. Improving the standards development process—create value-added standards in less time.
  2. Standards integration speed—ensure the clients and internal stakeholders get the new information when needed.
  3. Surveyor scheduling changes—reduce surveyor rescheduling, which wastes time, costs money and frustrates surveyors.
  4. Safety products value sharing—communicate the new services that are not being shared as much as forecasted.
  5. Consistency of standards interpretation—reduce the occurrence of customer dissatisfaction in standards interpretation.

Tackling inconsistencies

The standards interpretation project was important for a team to tackle, because customers want consistency in the interpretation of standards, and the Joint Commission has to find the sources of inconsistent interpretations supplied to them, Morrow said.

"One of the top five customer concerns is consistency in interpretation of the standards," Mowll said. "Either inconsistencies are being made among the survey team or occurring from one survey team to the next survey team. Some survey teams will tell a hospital one thing, while another team tells them something else."

For example, the team in charge of the project found that an external consulting source was interpreting a standard for medication storage differently than the Joint Commission does, Morrow said. "We also found different interpretations between other stakeholders," he added.

To reduce inconsistencies, the team first gathered the opinions of customers by contacting them directly, either by telephone or through web-based surveys, Morrow said. "The team also used Pareto analysis to identify the most frequent problem interpretations received by the Joint Commission’s standards interpretation group. Then, the team collaborated with the standards development group to ensure that it had the correct interpretations to develop solutions."

A variety of lean and change management tools were used for this project, including:

  • Chartering.
  • Stakeholder analysis.
  • Voice of the customer.
  • Hypothesis testing.
  • Surveying technology.
  • Supply, input, process, output, customer diagram.
  • Failure mode effects analysis.
  • Statistical process control.

The team developed a package of solutions called the Standards Pak to aid organizations in standards interpretation, Morrow said. "A Standards Pak for a standard is a set of documents that includes a description of the standard, implementation expectations, information about how the Joint Commission assesses compliance with the standard, definitions of key terms associated with the standard, supporting documentation and historical information about the standard," he added. The Joint Commission is currently testing this solution.

The teams involved with the five projects had formal report-outs—meetings in which team members discussed the project’s progress, successes and challenges—after every step, Benedicto said. "It was mandatory for the leadership and a growing number of team members," she added. "Those stimulated some very interesting discussions, which I think the teams benefited from. They got the benefit of perspective on the issue they were trying to tackle from all sides of the organization. The GBs were coached to look for teachable moments." 

Chassin required that all officers attend the report-out discussions, even if it meant changing schedules. "It was a very clear message from the president about how important this was going to be, but it also let all the other people know that this was something the leadership of the organization was committed to," Schyve said. "This wasn’t just the president’s idea."

Looking to the future

The Joint Commission is committed to internal lean Six Sigma projects over the long term. Chassin and Benedicto are certified belts, and they continue to coach others, Morrow said, adding that "this shows our top leadership is committed to robust process improvement. The Joint Commission is committed to further improving our processes and assisting customers where requested."

Now, the staff is focused on 10 additional projects, and there are many more from the first wave of belts who are now working on their second projects, Morrow said. Additionally, another 20-plus GBs and 20 change agents are being trained.

With the work being done on these projects to help with in-house continuous improvement, the Joint Commission believes the internal changes will also be successful outside.

"For many years, the Joint Commission tried to encourage continuous improvement in healthcare, but never with this level of emphasis," Schyve said. "It’s not as if the Joint Commission hadn’t been focused on improving processes, but we think this change will be helpful to healthcare organizations."

Source: ASQ

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